Rapidarc IGRT Radiotherapy at Apollo BSR Bhilai,Chhattisgarh

1. I.G.R.T: I.M.R.T/ RAPIDARC (FIRST IN C.G)
Image Guided Radiotherapy in Cancer

2. RAPIDARC UNIQUE
VARIAN
LINEAR ACCELERATOR
NEW RADIOTHERAPY
SET-UP
DR. PUNEET SETH
M.B.B.S (Bhopal), M.D Radiotherapy (Indore)
Consultant, Radiation Oncology,
BSR Cancer & Research Institute,
Apollo-BSR Hospital, Bhilai (C.G)
Previously at:
STT (Short term trained), I.R.C.H, A.I.I.M.S, New
Delhi (Feb 2007)
Registrar, Indraprastha Apollo Hospital , New
Delhi (May 2007-Dec 2008)
Senior Registrar, CBCC-USA Apollo, Ahmedabad,

3. ABOUT MY PAST 5 YRS WORK EXPERIENCE AT:
I.R.C.H, A.I.I.M.S NEW DELHI
2007 IMRT/SRS/SRT Gamma knife ( Elekta/ Varian)
INDRAPRASTHA APOLLO HOSPITAL, NEW DELHI
2007-2008 IMRT/SRS/SRT (Varian)
CBCC-APOLLO, AHMEDABAD
2008 -2009 IGRT/IMRT/SRS/ Brachytherapy (Varian)
G.R.MEDICAL COLLEGE, GWALIOR
2010 till Nov 2010 (BHABHATRONIC-II) 2D/3DCRT

4. Cancer’s Seven Warning Signals
CAUTION
• Changes in bowel or bladder habits
• A sore that does not heal
• Unusual bleeding or discharge
• Thickening or lump in breast or elsewhere
• Indigestion or difficulty in swallowing
• Obvious changes in warts or moles
• Nagging cough or hoarseness

5. Background
Estimated new cancer cases each year is expected
to rise from 11 million (2002) to 16 million (2020).
60% (9.6 million) of all these new cases will occur
in the less developed world.
These individuals, their families will face the
challenge of understanding cancer, and how it
affects their lives.
Providing quality & current cancer information to
cancer patients, their families, laymen & health
care givers is a key function

8. New cancer cases on the rise
10
16
9
million
new cancer cases (millions)
8
developing
in 2020
countries
7 a 50%
6
10 million increase!
industrialized
in 2000 countries
5
4
3
1990 1995 2000 2005 2010 2015 2020
year
WHO (2003)

9. Issues Facing Developing World
1. Patient Load.
Specialized centers are few and overwhelmed with
patients.
2. Treatment Priorities
Available agents e.g. chemotherapy and radiation
facilities impose choice of management.
3. Impact of existing health problems
4. Hepatitis and nutritional status affect management
significantly.
5. Compliance
Lack of interest in long term follow up due to
economic, cultural and educational reasons.

10. 6. Lack of communication between regional
centers in patient follow up & management.
7. Poor registration and follow up facilities.
8. Lack of integrated aproach to:
a)appropriate medical surveillance for late
effects of treatment.
b)counseling services.
c) special needs concerning employment,
disability, insurance, psychological support.

11. Obstacles/Barriers to Research
1- Financial constraints:
2-Lack of full time research career path.
3- Lack of motivation towards research
career pathway
4- Variation in research interest/abilities
within different centers

12. Membership in International
Organizations
• European organization for research and
treatment of cancer (EORTC).
• International Union Against Cancer (UICC)
• World Health Organization (WHO)
• International Atomic Energy Agency (IAEA)
• International Network for Cancer Treatment and
Research (INCTR)
• Eastern Mediterannean Regional Office/World
Health Organization (EMRO)

13. CHANGING LIFESTYLE : INVITATION TO CANCER

16. Nurse
Co-ordinator
Surgical Medical
Oncologist Oncologist
Radiation
Dietitian
Oncologist
Social OFM
Worker Patient Surgeon
Reconstructive Radiologist and
Surgeon PET expert
Speech
Pathologist
Pathologist
Dental
Oncologist

21. RADIOTHERAPY….TIME HISTORY
I.G.R.T

23. HISTORY OF RADIOTHERAPY

24. How Radiotherapy works?
• High energy X-Rays interact with DNA.
• Direct/Indirect of DNA damage - Ionisation of water molecules
cause DNA damage such as ‘Double strand breaks’

25. Overview of Radiotherapy
3 DCRT IMRT
Teletherapy IGRT/RAPIDARC DART Tomotherapy
Gamma Knife
Radiation
Stereotactic radiotherapy LINAC based
Therapy
Cyberknife
Image Assisted Brachytherpy
Brachytherapy
HDR/LDR Brachytherapy

28. Life inside a LINAC Prototype

30. An overview of:
Intensity Modulated Radiation Therapy
Image Guided Radiation Therapy

32. VARIAN IGRT vs ELEKTA IGRT

34. I.G.R.T : E.P.I.D (Electronic Portal Imaging Device)
& Multileaf Collimator (MLC)
No more
lead blocks!

35. IMAGING IN RADIOLOGY

41. Novalis Body System (BrainLab, Hermstetten,Germany).

45. BSR CANCER HOSPITAL…June 2001
APOLLO BSR, BHILAI……..Sept 2007
CENTRAL INDIA COMPREHENSIVE CANCER SET-UP
RADATION ONCOLOGY (COBALT ATC-9.. MAY 2008 NEW SOURCE )
SURG. ONCO, MED. ONCO, NUCLEAR MEDICINE, BLOOD BANK
4000 + CANCER PATIENTS SUCCESSFULLY TREATED…
NEW LINEAR ACCELERATOR.. UNIQUE 6 MV …
IGRT/RAPIDARC
INSTALLATION BY 2012 (DEC)…2013

46. BSR CANCER OLD SET-UP COBALT (ATC-9)

47. 2D PORTALS: PAROTID AT RISK

48. 2D PLAN

49. 2D PLANNING Vs IMRT PLANNING

50. WHATS THE NEED FOR NEW SET-UP ?

53. INDRAPRASTHA APOLLO, NEW DELHI
VARIAN 600-CD LINAC WITH BRAINLAB

54. APOLLO CBCC USA, AHMEDABAD Varian (Linac-ix)
IGRT- South East Asia's First

58. CHHATTISGARH :CHITRAKOT

59. CHANGING INDIAN SCENERIO WITH TIME :LINAC
LINAC 2011
Total : 135+ To be installed : 25
Number of Centers: 100+

60. NEW SETUP : UNIQUE LINAC
I.M.R.T , I.G.R.T , RAPIDARC

62. UNIQUE linear accelerator
• Millennium™ MLC
• RapidArc® and dynamic IMRT
• Small footprint
• Patient protection system
• Easy installation & commissioning
• Exact couch carbon fiber table top
• Enhanced dynamic wedge saves
time

63. Linear Accelerator – 6MV
• Treatment planning: CT
• Quick and painless!
• Multiple treatments
fractions.
• Dose and number of
treatments depends on
– Intent (Radical / Curative
Palliative, Post op.
Adjuvant)
– Sensitivity of tumour
– Sensitivity of normal
tissues

65. The Tools for the Radiation Oncologist
• Sophisticated treatment machines
(dual energies, multileaf-collimator, 3 paired laser beams
for patient set-up, integrated CT, IMRT, stereotactic
treatment)
• Tumor volume definition: CT-MRI-PET fusion
imaging, dedicated planing CT
• Treatment planing: Standardized dose prescription to
tumor (maximal) and to normal tissue (minimal),
dose-volume histogram for tumor and each organ at risk
• Treatment delivery: fix RT-field(IMRT), moving RT-
field (IMRT/RAPIDARC), image guidance, respiration
correction
• Fractionated (daily) radiotherapy to a defined total dose

66. Ionizing Radiation: The physical tools
Photons: - High energy X-rays (MV for LINAC)
- Skin sparing effect
- Dose decrease 2-5% /cm tissue
Electrons: - Charged light particles
- No skin sparing effect, limited depth
- Steep dose decrease after a few cm‘s
Protons: - Charged heavy particles
- unique dose distribution (matterhorn
like – Bragg Peak)

67. Integration of Molecular Biology
• Biology, Physics and Clinical Oncology
are the 3 pillars of Radiation Oncology
• Defined biologic model systems available:
> 30 years experience in classic radiobiology
• Molecular key targets for radiosensitization: (search)
for novel RT-sensitizers... Past 10 years
• Stem cell research, human genome project,
microarray technology: Implications for clinical
radiation oncology....Present and future

68. Pre-clinical research: Potential molecular
targets for RT-sensitizers in lung cancer
1970
Radiobiology 2008

69. PROTOCOL
- Most of the patients are given chemotherapy
(Cisplatin based) concurrently every week.
- Patients are explained regarding IMRT/IGRT
process, benefits & toxicities.
- All patients undergo thorough clinical
evaluation, staging & complete profile (bio-
chemical & radiological).
- Patients are evaluated at regular intervals during
the treatment for tumour response & toxicities.

70. How much radiation? DOSE OF RT
1 “rad” = 1 centiGray (cGy)
100cGy = 1 Gy
200 cGy / 2 Gy per day
5 days per week
MON-FRI
1000 cGy/ 10 Gy per week
H N SCC 60-70 Gy in 6-7 Week
Weekly Chemo: SUN/MON 5-6 CYCLE
Mostly CISPLATIN 30 mg/m2 ( 50-60 mg)

91. CRANIOSPINAL RADIOTHERAPY MEDULLOBLASTOMA

96. BILATERAL CARCINOMA BREAST

98. CARCINOMA ESOPHAGUS

108. COMING SOON…VARIAN UNIQUE

110. RAPIDARC /IGRT TEAM WORK
Radiation Oncologist: Contour & Review Plan.
RT Physicist: Performs CT Planning &
Quality assurance (Q.A)
RT Technologist: Handle patient care

116. T h a n k y o u